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Schies, Mark rIO`14N OF QUEEVBU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director IVGA^j NamelL�„ /�S Case # 333 Date of Cremation( —/T —Ty Time Cremation Started Time Cremation Completed /& !►'L,4 / -L� Type of Container 4?l?-agel9Pi VI✓ // �'i/ j 7 �/¢y Remarks : I /l� i/J ,C3lJ/ri�l�R 0,4 � i9//�/l f r , 1 / / M ► 3s" tti a ATTACH ALTl'H01MATION FOR CREMATION ANI) DISPOSITION BOOKLET HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING I/We,the undersigned, ce-,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and disposition of the remains of_ �� �(&; e S (hereinafter referred to as the"Deceased"). Name 6ED-eceased Date of Death A It) i 9 r J 'rune of Death ❑A.M. ❑P.M. I/We hereby request and authorize (iA� R# (hereinafter referred to as the"Funeral Home")to Nameo Funeral Home take possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we understand that the services and obligations of the Crematory shall he fulfilled when the cremated remains of the Deceased are returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes 51 No Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No ❑ Deliver to Cemetery Name and Address of Cemetery Release to family Name of esignated Family Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Homes agent ❑ Ship via U S Registered Mail* To: Name: Address: ❑ Other Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The authorized rein shall cremation laws ode rulesmregulations g and andon of the remains of the olio ess of the Crematory and Funedral Home, and the following b performed s and c nditions:accordance with all $ g � , P n' 1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncombustible materials, I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard When placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT Z6 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition Description of Implanted Device Disposition If no instruction for disposition is given, such items may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will he totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they may be separated from the cremated remains of the Deceased and disposed of by the Crematory. 5 not limited to hereby ,hinges,latches,thorize the mnailsr Crematory and prec to separate d remove from the cremation ious metals,and to dispose o{such chamber at noncombustible materials, including, but 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 0 r .1 _. I-- ___— __ ___,._:___ :- +,. ,,,,.,,.......,,,h+o ill „I 4-ha nmma+Prl mmaina of +h,P T)eneaaed. anv excess cremated DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to disposq of the cremated remains as follows : Mail to Other arrangements — please specify : If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1 . . The crematorium will be open For cremations 5 days• a week 7 :00 A. M. — 3 : 30 P. M. Monday—Friday. No ' Holidays or Sundays, arrangements can be made For Saturday. Prearrangements by telephone for acceptance of remains is necessary. 2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 3. An authorization For cremation properly signed by the nearest next of kin or other authorized person stating that they do have the power, -and authority to arrange For the cremation of the remains and to direct the disposition of the cremated remains, -that - any personal possessions have either been removed or may be destroyed and agree to protect , defend and save" harmless Pine View Crematorium from any and all claims. and demands for loss of damages which may be made against them by reason of or connected with the cremation of said remains and/or disposition of said . remains as directed, whether such claims or demands are, or are not wholly groundless, false or fraudulent . This authorization in addition to a regular burial permit must accompany the remains. 4• ., All,, remains must be encased in a casket or suitable alternate r container. Caskets and containers must be of combustible watt�er' �iatl C No styrafoam or plastic_ containers will be accepted. S:"x The `question relative to cardiac pacemakers must be answered on`' tlie"'auth'ori`zation to cremate re e remains form before the will be ` accepted. -- Unless other arrangements are made the cremated remains w to the ill be mailed •via Registered U. S. Mail within three days of cremation funeral home handling the service. Ther charge—for- this service. e will boa t2Q), 00 Cremation, Administration Costs and Recording Fe.Chj1d.re.n.,.,.,_(age.. 13 months to 12 years ) ti1 e : -Adult t1� 5. 00 ,0. 00 Infants ( stillborn to 12 month1s )"+-t�0. 00 • TOWN OF QUEENSUURY3 PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) Cr�e'mat or i um 745-447'7 or if no answer Cemetery 745-4476 AUTI•IOIZ I ZAT I ON TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of : (Name) (Sex ) 1 S 6-kt S C �Y1 I a (Street ) - (City ) (Sta e) ( Zip Code ) who died on 1 V day of 19 at -�iJ-,(-L C-!(- pz�i r (Place) (Address ) Name_ and, . address of nearest living relative or name of person authorizing cremation : :(Name) (Address ) Re1ati,oriship to the de eased S �e� Nance 'of Funeral Home IMPORTANT: (`'represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (Circle One ) I' certify"that I have the full power and •aut:horization to arrange 'f or" the' crematfon of the remains and to direct the disposition of the' crem;aced ` remains, that any personal possessions have either been removed or may be destroyed, and agree to protect, defend "and) saye h"aimless Pine View Crematorium from any and all claims and'Vem'and'st�for' loss :or damages which may be made against them by reason of or connected with the cremat.-io.n of said remains as directed, whether such claims or demands are or are not wholly groundl'es's';`!_'fals'e or 'fraudulent . Witness ) (Address ) (Signature of Relative or Legal Rep. and Address) Signed on this date : 13 "j r